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Pancreas Anatomy
Updated: Dec 07, 2017
Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Thomas R Gest, PhD

Overview
The pancreas, named for the Greek words pan (all) and kreas (flesh), is a 12-15–cm long J-shaped (like a hockey stick),
soft, lobulated, retroperitoneal organ. It lies transversely, although a bit obliquely, on the posterior abdominal wall behind the
stomach, across the lumbar (L1-2) spine (see the image below).[1, 2, 3, 4, 5]

Pancreas anatomy.

Embryology
The pancreas develops as 2 buds (outpouchings) of endoderm from the primitive duodenum at the junction of the foregut
and the midgut. A small ventral bud (pouch) forms the lower (inferior) part of the head and the uncinate process of
pancreas, whereas a large dorsal bud (pouch) forms the upper (superior) part of the head as well as the body and tail of the
pancreas. The ventral bud rotates behind the duodenum dorsally from right to left and fuses with the dorsal bud, and the
duct of the distal part (body and tail) of the dorsal bud unites with the duct of the ventral bud to form the main pancreatic
duct (of Wirsung). Because the common bile duct (CBD) also arises from the ventral bud, it forms a common channel with
the main pancreatic duct. The remaining proximal part (head) of the duct of the dorsal bud remains as the accessory
pancreatic duct (of Santorini).

Gross Anatomy
Anatomic anatomy

The pancreas is arbitrarily divided into head, uncinate process, neck, body and tail. The pancreatic head constitutes about
50% and the body and tail the remaining 50% of the pancreatic parenchymal mass.

The pancreas is prismoid in shape and appears triangular in cut section with superior, inferior, and anterior borders as well
as anterosuperior, anteroinferior, and posterior surfaces. On the cut surface of the pancreas at its neck, the main pancreatic
duct lies closer to the superior border and the posterior surface.

The head of the pancreas lies in the duodenal C loop in front of the inferior vena cava (IVC) and the left renal vein (see the
following images). The uncinate process is an extension of the lower (inferior) half of the head toward the left; it is of varying

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size and is wedged between the superior mesenteric vessels (vein on right, and artery on left) in front and the aorta behind
it.

The duodenum and pancreas.

The pancreas and duodenum, posterior view.

The lower (terminal) part of the common bile duct runs behind (or sometimes through) the upper half of the head of
pancreas before it joins the main pancreatic duct of Wirsung to form a common channel (ampulla), which opens at the
papilla on the medial wall of the second part of the duodenum.

The neck of the pancreas lies in front of the superior mesenteric vein, splenic vein and portal vein junction. The body and tail
of the pancreas run obliquely upward to the left in front of the aorta and left kidney. The pancreatic neck is the arbitrary
junction between the head and body of the pancreas. Portal vein lies behind the neck of the pancreas; no tributaries drain
from the posterior surface of the pancreas into the anterior surface of the portal vein; therefore, a tunnel can be easily
created behind the neck of the pancreas before its division. The narrow tip of the pancreas tail reaches the splenic hilum in
the splenorenal (lienorenal) ligament.

The duodenum (25 cm long) is horseshoe-shaped, with its inferior limb longer than the superior, and has 4 parts: (1)
superior (5 cm) at the level of L1; (2) descending, or C loop (7.5 cm), at L1-L3; (3) horizontal, or transverse (10 cm), at L3;
and (4) ascending (2.5 cm), leading to the duodenojejunal flexure (junction).[1, 2, 3, 4, 5]

The transverse mesocolon (with the middle colic vessels in it) is attached to the anterior surface of the lower (inferior) part of
body and pancreas tail; thus, most of the gland is located in the supracolic compartment. The body and tail of the pancreas
lie in the lesser sac (omental bursa) behind the stomach.

Radiological anatomy

The head of the pancreas lies in front of L2 vertebra, the body lies in front of L1 vertebra, and the tail lies at the level of T12
vertebra; pancreatic parenchymal calcification/ductal calculi in chronic pancreatitis is seen at these levels on plain
radiography of the abdomen.

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CT anatomy

The pancreas is best evaluated with a triphasic (arterial, portal venous, and systemic venous phases), contrast-enhanced
(after intravenous injection of contrast medium), computed tomographic (CT) scan with 3-dimensional (3-D), triplanar (axial,
coronal, and sagittal planes) reconstruction. Because the pancreas lies obliquely, all parts of the pancreas are not at the
same transverse level and are not seen in 1 section (cut) of the CT scan—the pancreatic head is lower (at the level of L2)
than its body (L1) and tail (T12). The normal pancreatic duct may be just seen in the head (3-4 mm diameter) and proximal
body (2-3 mm diameter) of the pancreas on CT scan. See the images below.

Computed tomography (CT) scan showing the pancreas head (*) and the superior mesenteric artery (black arrow) and
vein (white arrow).

Computed tomography scan of the uncinate process of the pancreas (*) behind the superior mesenteric vessels (arrow).

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Computed tomography scan of the body of the pancreas (*) with the splenic vein (arrow) behind it.

Computed tomography scan of the tail of the pancreas (*) reaching the hilum of the spleen (arrow).

Endoscopic anatomy

The main pancreatic duct (of Wirsung) runs from the tail through the body to the head of the pancreas where it descends
into the lower (inferior) part of the head. There, it joins the duct of the uncinate process coming from left and then the lower
part of the common bile duct to form a common channel (called the hepatopancreatic ampulla, when dilated), which runs
through the medial duodenal wall and opens on the dome of the major duodenal papilla (a nipplelike projection on the
medial wall of the middle segment of the second part [C loop] of the duodenum). Both the ampulla and papilla are
eponymously related to Vater.

A smooth muscle sphincter (of Oddi) is present around the common channel of the pancreatic duct and the common bile
duct; this prevents reflux of duodenal juices into the pancreatic duct (and the common bile duct). Another individual smooth
muscle sphincter is present around the terminal part of the main pancreatic duct before it joins the common bile duct; this
prevents reflux of bile into the pancreatic duct (a similar sphincter present around the lower part of the common bile duct
prevents reflux of pancreatic juices into the common bile duct).

An accessory pancreatic duct drains the upper (superior) part of the head of the pancreas and opens in the duodenum at
the minor duodenal papilla 2 cm anterosuperior to the major papilla (see the following image). The 2 pancreatic ducts (main
and accessory) often communicate with each other.

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The pancreatic duct.

EUS anatomy

Endoscopic ultrasonography (EUS) is the latest technical tool to evaluate the pancreas. An ultrasonographic probe is
mounted at the tip of an upper gastrointestinal endoscope (UGIE), which is passed into the second part (C loop) of the
duodenum. The pancreatic head, distal (terminal) parts of the pancreatic ducts (main and accessory), lower (intrapancreatic)
part of the common bile duct, and pancreaticoduodenal lymph nodes are very well visualized on EUS.

Blood supply

Pancreas derives a rich blood supply from both celiac axis and superior mesenteric artery, with collaterals between the two
systems; that is why when angiography is done for bleeding as a complication of acute pancreatitis, chronic pancreatitis or
pancreatoduodenectomy both celiac axis and superior mesenteric artery should be evaluated.

The celiac trunk (axis) comes off from the anterior surface of the aorta at the level of T12–L1. It has a short length of about 1
cm and trifurcates into the common hepatic artery (CHA), splenic artery, and left gastric artery (LGA). The CHA runs toward
the right on the superior border of the proximal body of the pancreas, and the splenic artery runs toward the left on the
superior border of the distal body and tail of the pancreas.[1, 2, 3, 4, 5]

The superior mesenteric artery (SMA) comes off from the anterior surface of the aorta just below the origin of the celiac
trunk at the level of L1 behind the neck of the pancreas. Then, it descends down in front of the uncinate process and the
third (horizontal) part of the duodenum to enter the small bowel mesentery.

The gastroduodenal artery (GDA), a branch of the CHA, runs down behind the first part of the duodenum in front of the neck
of the pancreas and divides into the right gastro-omental (gastroepiploic) artery (RGEA) and superior pancreaticoduodenal
artery (SPDA), which further bifurcates into anterior and posterior branches. The inferior pancreaticoduodenal artery (IPDA)
arises from the SMA and also bifurcates into anterior and posterior branches.

The anterior and posterior branches of the SPDA and IPDA join each other and form anterior and posterior
pancreaticoduodenal arcades in the anterior and posterior pancreaticoduodenal grooves supplying small branches to the
pancreatic head and uncinate process of the pancreas as well as the first, second, and third parts of the duodenum (vasa
recta duodeni). Multiple pancreatic branches (including a dorsal pancreatic artery, great pancreatic artery or arteria magna
pancreatica) of the splenic artery supply the pancreatic body and tail. Multiple, small pancreatic branches of a dorsal
pancreatic artery from the splenic artery and an inferior pancreatic artery from the superior mesenteric artery supply the
body and tail of pancreas.

The arterial supply of the pancreas forms an important collateral circulation between the celiac axis and superior mesenteric
artery.

Veins accompany the SPDA and IPDA. Superior pancreaticoduodenal veins (SPDVs) drain into the portal vein and inferior
pancreaticoduodenal veins (IPDVs) drain into the superior mesenteric vein (SMV). A few small, fragile uncinate veins drain
directly into the SMV. Some veins from the head of the pancreas drain into the gastrocolic trunk. Numerous small, fragile
veins drain directly from the pancreatic body and tail into the splenic vein.

The SMV lies to the right of the SMA in front of the uncinate process and the third part of the duodenum. The splenic vein
arises in the splenic hilum behind the tail of the pancreas and runs from left to right on the posterior surface of the
pancreatic body. Union of the horizontal splenic vein and the vertical SMV forms the portal vein behind the neck of the
pancreas.

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The inferior mesenteric vein (IMV) joins the splenic vein (or the junction of the splenic vein and SMV, or even SMV). The
portal vein receives the SPDVs, right gastro-omental (gastroepiploic vein, left gastric vein (LGV), and right gastric vein
(RGV); then, it runs up (superiorly) behind the first part of the duodenum in the hepatoduodenal ligament behind (posterior
to) the common bile duct on the right and proper hepatic artery on the left.

The portal venous system (splenic vein, SMV, and portal vein) has no valves.

Lymphatic drainage

The head of the pancreas drains into pancreaticoduodenal lymph nodes and lymph nodes in the hepatoduodenal ligament,
as well as prepyloric and postpyloric lymph nodes. The pancreatic body and tail drain into mesocolic lymph nodes (around
the middle colic artery) and lymph nodes along the hepatic and splenic arteries. Final drainage occurs into celiac, superior
mesenteric, and para-aortic and aortocaval lymph nodes.[1, 2, 3, 4, 5]

Nerve supply

The pancreas receives parasympathetic nerve fibers from the posterior vagal trunk via its celiac branch. Sympathetic supply
comes from T6-T10 via the thoracic splanchnic nerves and the celiac plexus.[1, 2, 3, 4, 5]

Microscopic Anatomy
The pancreas is a composite gland containing both exocrine and endocrine components. Acini, formed of zymogenic cells
around a central lumen, are arranged in lobules. Each lobule has its own ductule, and many ductules join to form
intralobular ducts, which then form interlobular ducts that drain into branches of the main pancreatic duct.

Under stimulation of secretin and cholecystokinin (CCK), the zymogenic cells secrete a variety of enzymes — trypsin
(digests proteins), lipase (digests fats), amylase (digests carbohydrates), and many others. Ductular cells produce
bicarbonate, which makes the pancreatic fluid (juice) alkaline.

Scattered throughout the gland are pancreatic islets (clusters) (of Langerhans) containing beta cells (about 75% of islets;
these secrete insulin), alpha cells (about 20% of islets; these secrete glucagon), delta cells (these secrete somatostatin),
and several other hormone-secreting cells. Islets constitute only about 2% of the pancreatic parenchyma.

Natural and Pathophysiologic Variants

Natural variants

The main pancreatic duct and common bile duct may not unite to form a common channel and open separately at the major
duodenal papilla. In addition, an aberrant (normal vessel is not present) right hepatic artery (RHA) may arise from the
superior mesenteric artery (SMA) and accessory RHA (in addition to the normal one from common hepatic artery [CHA])
from the SMA.[1, 2, 3, 4, 5]

Pathophysiologic variants

An annular pancreas is caused by failure of rotation of the ventral bud of the pancreas. A ring of pancreas is present around
and obstructs the second part (C loop) of the duodenum. Neonates with this pancreatic variant present with vomiting;
abdominal x-rays show a double-bubble (gastric and duodenal) appearance. Treatment includes bypass in the form of
dudodeno-jejunostomy (and not division of the pancreatic ring because it may result in pancreatic juice leak and fistula).

Pancreas divisum is due to failure of the main (Wirsung) and accessory (Santorini) pancreatic ducts to fuse. In addition to
the upper (superior) half of the head of pancreas (which it normally also drains), the accessory pancreatic duct (of Santorini)
also drains the body and tail of pancreas. This drainage may not be adequate (because of the smaller size of the accessory
duct) and may cause functional obstruction, resulting in recurrent attacks of acute pancreatitis. The main pancreatic duct (of
Wirsung) drains only the lower (inferior) half of the head and uncinate process and does not communicate with the
accessory duct (of Santorini).

A long (> 15 mm common channel of pancreatic duct and common bile duct is described as anomalous pancreatio biliary
ductal junction/ union (APBDJ/ APBDU) - it is associated with choledochal cyst and carries a higher risk of biliary
malignancy. APBDJ/ APBDU without cystic dilatation of the common bile duct carries a high risk of gallbladder cancer and is
an indication for preventive cholecystectomy.

Accessory pancreatic tissue may be present in the stomach, small intestine, Meckel diverticulum, omentum, and hilum of
spleen as soft yellow nodules/lobules.

Polycystic disease may involve the pancreas in addition to the more commonly involved organs (ie, liver and kidneys).

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Clinical Implications
Periampullary cancers include those of the lower common bile duct, ampulla, pancreas head, and duodenum (including
papilla) within 1-2 cm of the ampulla. Pain of pancreatic origin in acute pancreatitis, chronic pancreatitis, and pancreatic
cancer is felt in the epigastrium and bores into the back; it is aggravated when lying down and may be relieved by sitting and
bending forwards. Transmitted aortic pulsations can be seen and felt in pancreatic masses (tumors and cysts) as the
pancreas lies on the aorta.

Imaging considerations

Pancreas is difficult to visualize on ultrasonography as it lies behind the stomach and within the C loop of the duodenum.

Inflammatory thickening of the anterior layer of the left perirenal (Gerota) fascia is seen on CT scanning in acute
pancreatitis.

Using a side-viewing endoscope (SVE), the pancreatic duct (and the common bile duct) can be cannulated through the
papilla and radiographs obtained after injecting contrast, which is called endoscopic retrograde cholangiopancreatography
(ERCP).

Endoscopic ultrasonography (EUS) can detect small stones in the lower part of the common bile duct (not detected on
regular ultrasonogram) and small tumors in the head of the pancreas (not detected on computed tomography [CT] scan).
EUS can also be used to detect early changes of chronic pancreatitis and diagnose pancreas divisum and for guided fine-
needle aspiration cytology (FNAC) from pancreaticoduodenal lymph nodes.

Surgical considerations

The following should be kept in mind when considering surgical intervention in pancreatic disorders:

Trauma to lumbar spine, especially at the level of L2 vertebra, may result in pancreatic neck injury.

Retroperitoneal inflammation of acute pancreatitis spreads easily into perinephric and paracolic spaces.

Surgical obstructive jaundice occurs early in periampullary cancers because of common bile duct obstruction.

Pain of pancreatic origin may radiate to the back because of its retroperitoneal location.

Pancreatic head cancers manifest with surgical obstructive jaundice and gastric outlet obstruction because of
involvement of the common bile duct and duodenum.

The Cattell-Braasch maneuver is a downward (inferior) mobilization of the hepatic flexure of colon and right
transverse colon to expose the head of pancreas.

Kocherization is the mobilization of the second part (C loop) of the duodenum anterior and to the left to mobilize the
head of the pancreas; the inferior vena cava (IVC) and left renal vein are encountered posteriorly.

Opening the lesser sac by division of the gastrocolic ligament exposes the body and tail of the pancreas.

The most common site of fluid collection/ pseudocyst formation in acute pancreatitis is the lesser sac.

Cystogastrostomy for pancreatic pseudocysts is feasible because of the proximity of the posterior wall of the stomach
to the anterior wall of a pancreatic pseudocyst, which lies in the lesser sac.

During lateral pancreatico-jejunostomy (LPJ) for chronic pancreatitis, the incision in the main pancreatic duct (MPD)
should stop a few mm short of the pancreatico-duodenal groove to avoid injury to the anterior pancreaticoduodenal
arcade of vessels.

Pancreaticoduodenectomy is required for resection of pancreatic head and periampullary cancers because of the
shared blood supply between the head of pancreas and second part (C loop) of the duodenum.

Duodenum-preserving pancreatic head resection (DPPHR) may be performed for chronic pancreatitis with head
mass; a thin rim of pancreatic tissue along the duodenal C loop containing the pancreato-duodenal arcade of
vessels.

Infiltration of the superior mesenteric vessels (vein more often than artery) and the portal vein in pancreatic cancer
(head and uncinate process) makes them unresectable.

Pancreato-duodenal arcade acts as collateral between celiac axis and superior mesenteric artery. During
pancreaticoduodenectomy, gastroduodenal artery should first be temporarily occluded with a bulldog clamp before its
ligation and division; absence of proper hepatic artery pulsations after GDA occlusion indicates celiac artery stenosis.

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Infiltration of the middle colic vessels in the transverse mesocolon in the pancreatic head cancer may necessitate
resection of the transverse colon.

Aberrant and accessory right hepatic arteries arising from the superior mesenteric artery (SMA) may be at risk during
pancreaticoduodenectomy.

The pancreatic duct lies nearer to the upper border and the posterior surface of the pancreatic neck stump after
pancreaticoduodenectomy.

The margins of a pancreaticoduodenectomy specimen include the inferior uncinate mesentery (containing the inferior
pancreaticoduodenal artery and veins) and the posterior pancreatic mesentery (containing the posterior superior
pancreaticoduodenal artery and veins; anterior superior pancreaticoduodenal artery arises from the gastroduodenal
artery and lies in front of pancreas).

Thoracoscopic splanchnicectomy is used for relief of intractable pain in unresectable pancreatic cancer.

The tip of the pancreatic tail at the splenic hilum is liable to injury during splenectomy.

Contributor Information and Disclosures

Author

Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS Professor of Surgical Gastroenterology, Sanjay Gandhi Post Graduate
Institute of Medical Sciences, Lucknow, India

Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS is a member of the following medical societies: Association of Surgeons of
India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National
Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Chief Editor

Thomas R Gest, PhD Professor of Anatomy, Foundational Sciences Discipline, Central Michigan University College of
Medicine

Thomas R Gest, PhD is a member of the following medical societies: American Association of Clinical Anatomists

Disclosure: Nothing to disclose.

References

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University Press; 1986. Vol II: Thorax and Abdomen:

3. Grant JCB, Basmajian JV, Slonecker CE. Grant's Method of Anatomy: A Clinical Problem-Solving Approach. 11th ed. London,
UK: Williams and Wilkins; 1989.

4. Gray H. Lewis WH, ed. Gray’s Anatomy of the Human Body. 20th ed. New York, NY: Bartleby.com; 2000. [Full Text].

5. Sinnatamby CS. Last's Anatomy: Regional and Applied. 12th ed. Edinburgh, UK: Churchill Livingstone; 2011.

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